The November audio issue is posted! Highlights include:
-Do elderly patients wait longer?
-A delirium screening tool
-Do people who can’t afford their medicines come back to the ED more?
-Standoff: Canada and US — who does more CTs?
-The cost of emergency medicine, it’s not what you’ve heard
-NAC v IV fluids to prevent contrast nephropathy
-Unused IV lines
-UTI in renal colic patients – predictors and urinalysis utility
Check it out and email any time at email@example.com
Editor’s Note: In lieu of flowers, please consider a memorial donation to the Emergency Medicine Foundation. The family will be notified of any gifts received in his memory.
By Brian J. Zink, MD
Author, “Anyone, Anything, Anytime: A History of Emergency Medicine”
November 5, 2013
Life has sweet and sad moments, sometimes too closely juxtaposed. At the October 2013 ACEP Scientific Assembly meeting in Seattle, emergency physicians, residents, medical students, and long-time colleagues were pleased and intrigued to watch Dr. George Podgorny in the premiere of the EMRA Legacy Initiative 24/7/365 documentary, and then to hear him interviewed later that evening and in a panel discussion the following day. Many learned about the key role that Dr. Podgorny played in establishing emergency medicine (EM) as a legitimate US medical specialty through the creation of the American Board of Emergency Medicine (ABEM). At the time of the approval of ABEM by the American Board of Medical Specialties in 1979, Dr. Podgorny was clearly in the mix – serving as both President of ACEP and President of ABEM that year. He was integrally involved in the negotiations that created the approved “modified conjoint” ABEM board after the original ABEM proposal had been roundly defeated in an American Board of Medical Specialties (ABMS) House of Delegates vote in 1977. After ABEM was approved, Podgorny was the Chief Examiner for the first ABEM exam. He also became the head of the newly created Residency Review Committee and served in that capacity for 6 years. He tirelessly surveyed and approved residencies, helping to ensure the quality of new emergency medicine residency programs.
Unfortunately, after gracing us with his encyclopedic memory, wit, and insights at ACEP, Dr. Podgorny fell ill after his trip to Seattle and died in Winston Salem, North Carolina on November 5th, 2013.
George Podgorny was born in Iran, but his heritage was Czech and Armenian. His father taught physical education to the children of the Shah of Iran, and his mother wrote children’s books. It was decided that George would come to the United States after high school because the family felt that a US university education would be superior. Podgorny left his family and came alone to Maryville College in Tennessee and decided to go in to medicine. He became enamored with Wake Forest University School of Medicine (then the Bowman Gray Medical School) and its Baptist Hospital, was accepted there for medical school and never left the region. Podgorny excelled as a medical student and was accepted in to the general surgery residency. As a surgery resident he spent a great deal of time in the emergency department, and was struck by the fact that the sickest patients were cared for by the least trained residents who were rarely supervised. He worked diligently to improve care in the ED even as a resident. Podgorny then completed vascular surgery training and was in a cardiothoracic surgery training fellowship when he began to learn more about physicians who were practicing full time in emergency departments (EDs). He attended the 1970 ACEP meeting and met many of the early leaders. After this, he joined with a couple friends to work in the ED of Forsyth Hospital in Winston-Salem. He loved this work, and the possibility of being involved in a new specialty of medicine, and did not return to surgery.
As someone who was academically-oriented and had 7 years of residency training, Podgorny linked with the early ACEP leaders and began to push for formation and approval of a specialty board in EM. His background and connections in the surgical world helped to lend some credibility to the early group, and allowed him to battle the opposition that came from surgical fields. He came across as a unique individual, always sporting a handlebar mustache, with an exotic sounding accent and an eloquent but raspy voice. People paid attention when he spoke.
One of his most important roles came at the “Workshop Conference on Education of the Physician in Emergency Medicine” in Chicago in 1973. Podgorny was an important, persuasive figure in a comprehensive gathering of medical leaders from government, the other medical specialties, and academia. The fate of EM going forward hinged on the early EM leaders convincing others that the field was credible and that residency training and specialists in EM were just as important as in other medical fields. The outcome of the meeting was favorable and Podgorny and other early leaders in EM then made a concerted push, against considerable odds, to get ABEM established over the next 6 years. Podgorny was a key negotiator in the process, particularly in the final compromise that allowed ABEM to be approved in 1979.
George Podgorny continued to practice emergency medicine for many years in Greensboro, North Carolina after his direct leadership in ACEP and ABEM ended. However, he was a constant presence at the annual Scientific Assembly and offered advice and counsel to the new leaders in EM. On a personal level, George loved his Persian heritage, and his home was lavishly decorated with Persian art and furniture. He was a widely read intellectual, and an astute scholar of the history of medicine. He also loved his adopted home state of North Carolina, and was a regular at the local barbeque restaurants.
Dr. Podgorny is one a handful of people who can be considered to have been truly essential to the formation of emergency medicine. Without his forceful, scholarly, and gracious diplomacy, some of the early deliberations of the future of EM could have gone the other way. His loss leaves us greatly saddened, but we can also warmly reflect on how his determination, skill in negotiation, and perseverance made EM become a reality in the US. This is his tremendous legacy. We are grateful to have had the pleasure of seeing and hearing this senior icon of emergency medicine one last time at the ACEP Scientific Assembly 2013.
By Dr. Fernando Mirarchi
A 68-year-old male presents with a history of diabetes, hypertension, dyslipidemia, and CAD s/p CABG 10 years ago. Patient is experiencing chest pain. He is clammy. He is in mild distress. Vitals: T: 36C; P:60; RR:22; SaO2: 98%RA. The family gives you his list of medications and living will. Abruptly, the patient becomes unresponsive without palpable pulses. The monitor shows ventricular fibrillation. What next? Read the article, click here to look at the Will and take a two-question quiz.
Advance directives were created with the best of intentions, aiming to protect patient autonomy and honor end of life wishes. Until recently, the risks posed to patient safety by the various incarnations of advance directives were unknown and thus, undisclosed. Often, these well-meaning documents have produced unintended consequences. The TRIAD studies (The Realistic Interpretation of Advance Directives) have disclosed this patient safety risk as reality and on a nationwide scale. The risk is attributable to variable understanding and misinterpretation of advance directives which then translates into over or under resuscitation. At present, this is an unreported safety concern and only by clarifying the terms of advance directives and developing systems to educate providers will we be able to respect our patients’ wishes while still protecting their safety.
The living will was first legalized in California in 1977 and was known as the Natural Death Act.1 It was created by an attorney and utilized to decline life saving measures, essentially intended to provide patients with greater autonomy in end of life decisions. 2 Unfortunately, it also resulted in increasing risks to patient safety. Further fueling this patient safety risk was the development of The Patient Self Determination Act 1990. 3 This mandate, which was never evaluated for safety, requires patients to be provided information regarding their right to execute an advance directive at institutions receiving Medicare/Medicaid funding. With 90 million living wills in existence in the United States, 4 incorrect interpretation can lead to deleterious impacts on the care and safety of patients who summon 911 or experience a medical emergency in a healthcare setting. Clarification of terms, education of providers and implementation of safeguards are needed to protect the safety and autonomy of patients. In the TRIAD III nationwide study, high percentages of participants reported receiving training related to advance directives. However, those indicating receiving education produced no benefit. As health care providers, we need to work together on a national level to improve this education process. To further facilitate understanding, the following terms need to be defined and standardized:
Terminal Illness defined by law
Reversible & Treatable Condition
An “Effective” Living Will
An “Enacted” Living Will
For purposes of clarification, the mere presence of a living will does not mean it should be followed. It simply indicates that this document is “effective,” or that it is valid and legal.5 It should not be followed at this point to guide the care and treatment of the patient.
An “enacted” or “activated” living will is one that has been activated by the triggers in the document, most commonly a terminal or end stage medical condition or a persistent vegetative state. 5 This “enacted” living will now necessitates adherence to its instructions regarding the care of the patient. A terminal or end stage medical condition has a legal definition which essentially states that a patient would be expected to die of their disease process despite sound medical treatment. Therefore, the mere presence of a living will “does not” dictate the care of a critically ill patient who presents with a reversible and treatable condition such as CHF or COPD; rather it applies when that same patient is permanently unconscious and has exhausted all treatment options. A do not resuscitate order (DNR) refers to an actual physicians order that directs health care providers not to intervene with CPR if the patient is found pulseless or apneic.6,7
Otherwise it should have no implication on the care and treatment that the patient is to receive.6,7
Despite the legal and societal definition of DNR, research reveals in the TRIAD studies that medical providers understand DNR to be synonymous with an order to provide comfort and end of life care.8,9,10 A relatively new document called the Physicians Orders for Life-Sustaining Treatment (POLST) is different as it is an order set to be followed that addresses the treatment options of a patient should they present in cardiac arrest as well as the patient’s preferences for care in a non-arrest situation.11
POLST is a national paradigm and its philosophy is being rapidly embraced on both a national and state level. Unfortunately, it is now being nicknamed the Pink DNR form. This nickname needs to be quickly clarified and resolved as patients can be designated as a Full Code or a DNR through the use of this form. This again is a situation where good intentions can have unexpected consequences. SafeGuards are created to promote patient safety. I would like to introduce the SafeGuard known as the Rescuscitation Pause (RP). The RP is a process similar to the surgical pause (time out is the correct term) which is already widely utilized to correctly identify patients and eliminate wrong site surgery. Resuscitation takes on many forms and is not limited to the cardiac arrest situation. Resuscitation takes place when a patient presents critically ill and requires active interventions for conditions such as respiratory distress, sepsis or GI bleeding, etc. Resuscitation takes place with conditions that require immediate evaluation and intervention such as trauma, cardiac and stroke system activations to define care and facilitate treatment. A Pause is a moment to quickly assess and reassess the situation to assure you are defining the appropriate care and treatment. Through the use of a secure, HIPPA protected and interactive educational platform, QuantiaMD, (www.quantiaMD.com) we have been able to educate over 24,000 medical providers and empower them with the RP as a patient safety tool. We have been able to confirm that the medical community nationwide supports the TRIAD concerns that there is a real and present risk to patient safety; they found the education and tool to be useful and have empowered it into their clinical practice.
Advance directives in their various forms have never been evaluated with regard to patient safety though they directly affect well over 90 million patients. This is a medical error and resolution of the issue will require increased awareness and education among medical providers of all disciplines. The Resuscitation Pause holds significant promise as a way to protect patient safety and autonomy. The importance of this issue cannot be overstated as understanding advance directives not only allows us to appropriately provide or withhold life-saving care, but also ensures that we safely honor our patient’s wishes in the process.
How to Interpret a Living Will <http://secure.quantiamd.com/player/yabhqcxpi?u=yxjzuqjvk>
What Do DNR Orders Really Mean? <http://secure.quantiamd.com/player/yafruujyt?u=yxjzuqjvk>
POLST: Physician Orders for Life-Sustaining Treatment <http://secure.quantiamd.com/player/ywebdxfnf?u=yxjzuqjvk>
Understanding Your Living Will; What you need to know before a medical emergency www.addicusbooks.com
Towers B. The Impact of the California Natural Death Act. J Med Ethics. 1978;4:96-8.
Kutner Luis. The Living Will: a proposal. Indiana Law Journal. 1969;44(1):539-554
Patient Self Determination Act http://nhdd.org/facts/
Source: U.S. Census Bureau, 2044 Population Estimates, Census 2000, 1990 Census (http://www.census.gov)
Mirarchi FL. Understanding Your Living Will. Addicus Books 2006
Do Not Resuscitate (DNR) Protocols within the Department of Veterans Affairs. Section 30.02
Code of Medical Ethics Opinion 2.22 Do-Not-Resuscitate Orders. http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion222.shtml
Mirarchi FL, Hite LA, Cooney TE. TRIAD I – The Realistic Interpretation of Advanced Directives. J Patient Saf. 2008;4:235-40.
Mirarchi FL, Kalantzis S, Hunter D. TRIAD II: Do Living Wills Have an Impact on Pre-hospital Life Saving Care? J Emerg Med.2009;36:105-15
Mirarchi FL, Costello E, Puller J, Kottkamp N. TRIAD III: Nationwide Assessment of living Wills and DNR orders. J Emerg Med. 2012 May;42(5):511-20.
Physicians Orders for Life-Sustaining Treatment (POLST) http://www.polst.org/
The Annals podcasts are available here: http://www.annemergmed.com/content/podcast
The highlights for October are:
-What predicts ‘drug-seeking’ or prescription misuse among ED patients?
-hydromorphone 1+1 opiate dosing
-metoclopramide vs ketorolac for ED headaches
-Cost-effectiveness of helicopter EMS
-Attitudes toward sickle cell crisis management
And much much more…
I’ve noticed something.
At tertiary care hospitals, such as Level 1 trauma centers, there are all manner of specialists on call for the emergency department. In fact all specialties are represented. There’s no need to transfer patients to a higher level of care. It makes sense. After all, these hospitals are affiliated with medical schools, have residency programs, carry on teaching and research and act as referral centers for a certain geographical area.
At community hospitals, i.e. those that are not designated as tertiary care or Level 1 or Level 2 trauma centers, there is almost never a full complement of specialists. Often there is no neurosurgery, no cardiothoracic surgery , sometimes no plastics, maxillofacial or vascular services. In many of these hospitals, though a significant portion of the emergency population is children, there is no pediatric ICU.
In other words, in many hospitals in the USA, patients with serious medical and/or surgical problems have to be stabilized by the emergency physician and then transferred to a higher level of care.
Who manages these critical care emergency patients? Who manages the trauma patients, until they are transferred out? The emergency physician, of course. All this requires great skill and competence. Ask anyone who’s done it.
Who manages these types of patients at the Level 1 trauma center? The on-call specialists do.
It is believed, by some, that ACEP Legacy physicians are not competent enough to work in tertiary care hospitals and certainly not capable of teaching medical students and residents.
It is also believed, by some, that Emergency Medicine Residency-Trained (EMRT) doctors are more competent than their non-EMRT counterparts.
So, if the EMRT doctors are more competent, why aren’t they working in the community hospitals where a higher level of skill is required?
Why aren’t the non-EMRT docs working at the trauma centers, where all the back-up is available? If we’re less competent, don’t we need all the help we can get?
If the EMRT docs are more competent, shouldn’t they be working at the hospitals where there is less back-up, fewer resources?
Has someone got this whole thing bass-ackwards?
Why are only EMRT docs working at the tertiary care hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
For the past 5 years I have been doing locum work abroad; in Canada, New Zealand and England and I’m currently looking at Australia. I haven’t applied for any jobs in US hospitals during that time. I live in Florida, have keep my medical license active and am considering exploring the possibility of working in Florida again in the near future.
Some of you might remember that previously I ran into problems applying for work in The Sunshine State, because I was not EM residency-trained nor ABEM-boarded. In spite of ACEP offering verbal support to the idea that Legacy physicians are an important part of the workforce and thus should be given consideration on merit and performance, in hiring situations, the reality was that most hospitals, especially those in desirable locations, were off-limits to doctors like me.
Numerous ads for ER jobs come into my email daily. A few years ago almost all of them “required” ABEM certification. Some even stipulated that applicants must be EM residency-trained, which, by the way, would exclude a number of ACEP past-presidents.
Lately there seem to be more than a few hospitals that will settle for certification in any primary care specialty, e.g. family medicine, internal medicine, etc. So, is the landscape changing? Are the realities of the workforce finally being realized by hospitals that find themselves in need of emergency doctors?
Do I have any hope of getting a job in a decent hospital in the Sarasota, FL area?
Is it any easier now for ACEP Legacy Physicians to get jobs in American hospitals?
I’m just asking.
Marlene Buckler, MD, FACEP, CCFP(EM), DABUCM
Official Blogger for ACEP Emergency Medicine Workforce Section
She was young, pretty, and dead. Another victim of a head-on collision on a stretch of winding road outside of town where we get the great majority of MVC’s in the rural hospital in which I work. We knew it was going to be bad when we heard the ambulance traffic call out the “Code Three with one” as it was en route from the accident site.
She was resuscitated, but after an hour we knew that nothing more could be done for her. After calling the code, my attention turned to the sometimes worst part of our job, notifying the next of kin. She had a cell phone in her bag, and on it “Mommy.”
I can still hear her voice as she cheerily answered “Hi! Good morning!” Had I been in a different frame of mind, I would have taken the time to try to figure out how to find the actual number in her contact list. But, Monday morning quarterbacking aside, I did what my instincts told me to do at that moment.
Once I said that her daughter had been in a serious accident, she immediately passed me off to the girl’s father “who was a doctor and would understand better.” I steadied my voice as I informed him that his daughter had died. I held the phone near my ear but somewhat away as the wails and cries filled the small space I was in. Their grief carrying across the hundreds of miles that separated us.
They would come right away, he reassured me. I told him to take his time and await our phone call. There were other calls that had to be made. To CHP. To the donor network. To the coroner. After about an hour, my nursing supervisor told me the family was coming and would like to stop by the hospital to talk to me.
Several hours and a multitude of patients later, they arrived. I spent some time with them explaining what I knew of the accident and about the resuscitation effort. As a doctor, he had a lot of questions and wanted to know everything in detail. Toward the end of the visit, I found out she had only recently moved and was actually working at one of our local shops.
Then I remembered her. A bright, smiling girl who helped me with a purchase not even a week ago. I tried to wrap my head around that image and not of the broken patient who had been brought to my ED just hours earlier. I’m still trying.
We’re posted for July! Highlights include:
-Validation of a decision rule for SAH
-Effects of a health information exchange on xray ordering
-Ocular fundus photography in the ED
-Renal impairment: a risk factor for ACS among chest pain patients?
-Training and real time A-V feedback effects on CPR success
-Clinical Policy: Management of Asymptomatic Hypertension in the ED
-Antibiotic stewardship: A review of mechanisms
-Cost-effectiveness of rapid flu testing
Email any time with comments or questions about the audio/podcast.
Fellow ACEP Members,
For those who made the trip to Denver this past October, hopefully you were able to “add more science to your Scientific Assembly experience” by visiting the ACEP Research Forum. The forum included both oral and poster presentations highlighting cutting-edge research in our field. The Forum featured an expert panel discussing abstracts that have significant implications for emergency medicine practice or research. Last year marked the first for the ACEP Research Forum Scavenger Hunt. In order to bring additional interest, and add a little fun to the Research Forum, a scavenger hunt was created with collaboration from the researchers themselves.
The scavenger hunt consisted of a set of questions for each day of the forum for non-researchers reviewing the posters to complete. The answers could be found in the poster presentations and each question was followed by a clue to guide you along the way. Questions for the hunt were contributed by over forty of the presenting researchers. The contributors were enthusiastic about the scavenger hunt, stating “It’s a great idea!! Very excited about it.” Another researcher appreciated that “It helped me not wait until the last minute to do my poster.” Summing up the goal of the scavenger hunt well, another contributor commented, “Thanks for increasing the awareness of the research projects.
Those who completed the scavenger hunt were submitted into a drawing for prizes: Virtual ACEP membership and ACEP bookstore gift certificates. One participant who completed the Scavenger Hunt commented, “It forced you to get a look at the whole range of research EM physicians are involved in, instead of gravitating only to your area of interest.”
Cutting edge research is presented every year at the research forum by hard working practitioners in our field. Efforts to increase awareness and participation by non-researchers in the forum should be continued. The Scavenger Hunt is again being planned for the upcoming conference, ACEP13 in Seattle. Be on the lookout for a new and improved Scavenger Hunt with improved convenience and ease of access. Of course, don’t forget about the exciting ACEP prizes for those cunning enough to navigate the hunt!
Alicia Glynn, MD
Case Western Reserve University/Metro Health Medical Center/Cleveland Clinic